Developing preventative approaches that address the social determinants of type 2 diabetes in high risk populations

Type 2 diabetes(T2D) is a common chronic condition associated
with increased cardiovascular risk, reduced life expectancy, and
considerable socioeconomic consequence[1]. In the UK, there are
approximately 3.8 million people living with diabetes, and by 2025
it is predicted that this will increase to 5 million[2]. However, the
distribution of T2D, its clinical course and its prognosis varies
widely[3], being highest amongst certain ethnic groups and those
of lower socioeconomic status (the so-called social gradient[4]).
For T2D prevention strategies to be effective at population level
and in the most high risk groups, it is likely that they will need to
address these social determinants in addition to focusing purely
on individual-level behavioural interventions[5].
Currently, the NHS delivers a large diabetes prevention program
("Healthier You") to individuals at high risk of T2D, based on trials
evidence showing that intensive individual behavioural
interventions are efficacious in reducing the risk of developing
T2D[6]. However, real-world effectiveness of these interventions is
inconclusive[7-9], which may, at least in part, reflect the fact that
individualised behavioural interventions do not adequately
address critical social determinants of T2D[10,11]. There is little
knowledge on how these wider social determinants might be
addressed alongside, or separate to, existing prevention
programmes. Research suggests that approaches that employ
social network-based interventions may deliver additional benefit
to individual behaviour changes approaches[12].
Social prescribing(SP) is another innovation being widely adopted
within the NHS policy[13-16]. It generally involves linking patients
in primary care with sources of support within the community[17],
providing a mechanism where healthcare professionals can offer
'prescriptions' not just for medical issues, but also for social
issues. These prescriptions might include referrals to community
services offering financial advice, cooking classes or exercise
programmes. It is being widely advocated as a way of addressing
the social determinants of long term conditions[9], such as T2D,
redressing health inequalities[18] and improving the efficient use
of NHS resources. However, evidence for the effectiveness of SP
is sparse[19, 20], its implementation is heterogeneous and
complex[21], and it incorporates little robust evaluation across
health domains[22]. As such, there are significant opportunities to
evaluate the potential impact of SP in areas of specific health
need (T2D risk) and context (a health system serving a
community at high risk and where existing preventative
interventions have low uptake).
The London Borough of Tower Hamlets offers an ideal setting to
undertake a critical evaluation of SP and its potential to address
the social determinants of T2D risk. Tower Hamlets is an ethnically
and socio-economically diverse inner-city district in the East End
of London, comprising pockets of significant deprivation with high
prevalence and risk of T2D. This study will build on evidence from
pre-existing SP schemes and a recent preliminary evaluation of
the borough-wide roll-out[23], and study the interaction of these
schemes with T2D prevention activities (Healthier You). Findings
will potentially benefit populations at high risk of T2D, by
understanding how the social drivers of the condition might be
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tackled with SP. It is hoped that findings will lead to direct
recommendations for improving local SP schemes relevant to
patients at risk of T2D and build a novel approach to their
integration with existing NHS prevention programmes. I would also
plan to contribute to national policy on SP and T2D prevention.
Aim: To investigate the potential of SP to contribute to T2D
prevention in populations at high risk, through its ability to
influence the social determinants of health